This invention relates generally to a medical documentation system for documenting patient care substantially electronically to reduce the amount of data entry and paperwork required for such documentation.
Medical care includes doctors, nurses, and other healthcare providers documenting patient care through use of handwritten notes, forms, narratives, electronic data entry, etc. Such documents may require a considerable amount of time to produce.
Alternately, healthcare providers may dictate observations, instructions, and procedures either contemporaneously while examining or otherwise treating the patient, or, thereafter. These dictated observations must then be transcribed in some manner into usable written reports, computer files, or other documentation formats. Such reports may be for the patient's use, the writer's use, referral information, treatment histories, archival, and/or regulatory purposes.
Accordingly, it would be desirable to have a system which eliminates, or greatly reduces, the amount of data entry and paper-based documentation by healthcare providers and also to provide improved access to such documentation once created.